Urinary Infection in Children

1
Urinary Infection in Children Vesico Ureteric
Reflux

• Dr. Ramesh Babu Srinivasan
• M.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin,
  FRCS (Paed)
• Paediatric Urologist
• Sri Ramachandra Medical Centre, Porur, Chennai,
  India

2
Why is UTI important in children ?
3
Childhood UTI

• 30-50 have underlying problems
• Symptoms can be vague diagnosis can be missed
• Failure to treat ? scarring hypertension loss
  of function renal failure

4
What is the Incidence ?

• 5 of girls and 2 of boys will have UTI during
  childhood
• Before 3m Boys more susceptible
• After 3m Boys Girls

5
What is the pathogenesis?
6
What are the symptoms ?

• Often non specific in neonates infants
• Suspect in any infant with unexplained fever gt 3
  days
• Any neonate with fever, lethargy, seizures
• Children fever, diarrhea, abdominal pain
• Older Children burning, urgency, frequency,
  flank pain, wetting, turbid or foul smelling
  urine.

7
What is the essential history in a child with
UTI?
8
History - underlying factors

• Constipation (pain, consistency / frequency)
• Bladder Instability (frequency, urgency)
• Dysfunctional voiding
• (holding, straining, Vincents Curtsey Sign)
• Toileting habits (position, wiping post void)
• Drinking history quantity quality bladder
  stimulants (caffeine, black currant)
• Bathing habits bubble baths, shampoo bath
• Family history/social history

9
How to diagnose a UTI?

• How to collect specimen?
• Rapid tests?
• Confirmation?

10
Definition

• Significant Bacteriuria presence of a pure
  growth of gt 105 colony forming units of
  bacteria/ml
• Lower counts may be important, in specimens
  obtained by urinary catheter
• Any growth clinically important if obtained by
  suprapubic aspiration

11
Definitions

• Simple UTI low grade fever, dysuria, frequency,
  urgency
• Complicated UTI fever gt38.5, vomiting,
  dehydration, renal angle tenderness
• Recurrent UTI Second attack of UTI
• Relapsing UTI UTI with same strain
• Breakthrough UTI UTI while on prophylaxis

12
Initial Management

• Send FBC, BU, S Cr, Electrolytes Urine
• Children with complicated UTI, infants lt 3m and
  those with systemic signs are admitted for IV
  antibiotics
• Adequate hydration is essential during acute
  phase
• USG and repeat urine culture are necessary if
  there is no improvement lt 48hrs
• If there is obstruction it needs to be relieved
• (catheter in PUV nephrostomy in pyonephrosis)

13
Initial Management

• Infants gt 3m and those with simple UTI oral
  antibiotics amoxycillin co trimoxazole or
  cephalosporin
• Usual duration of treatment is 10-14 days for
  complicated and 7-10 days for simple UTI
• After this course, start prophylactic antibiotic
  until further evaluation in all children lt 2yrs

14
Investigations after First UTI

• USG (KUB)

Abnormal
Normal
lt2yr 2-5 yr gt5yr
MCU, DMSA
MCU, DMSA DMSA no further test
MCU (if scar or DMSA not available)
15
Role timing of Investigations

• USG helps to detect PC dilatation, ureter
  dilatation, bladder thickening, ureterocele, post
  void residual (useful in acute phase when
  obstruction suspected)
• DMSA ideally after 3m to detect scarring
• MCU provides anatomical information of urethra /
  ureters grading of reflux possible
• Nuclear Cystogram Less invasive less radiation
  Older cooperative children required poor
  anatomical information grading difficult not
  ideal as first investigation useful for F/U of
  reflux

16
Recurrent UTI

• Children with recurrent UTI irrespective of age
  require USG, DMSA MCU

17
Antibiotic Prophylaxis

• Following First UTI in all children lt 2yrs
• Following complicated UTI in children gt 5 yrs
  while waiting for imaging
• Children with VUR (up to 5 yrs)
• Scars on DMSA even if there is no VUR (stop if
  repeat MCU or RNCU is normal)
• Children with frequent febrile UTI (? Even if
  imaging is normal)

18
Antibiotic Prophylaxis

• Age of Pt Duration
• First UTI
• Reflux All up to 5 yrs
• No reflux/ scar All 6m, re
  evaluate
• No reflux no scar lt 2 yrs 6m, re
  evaluate
• gt 2 yrs no prophylaxis
• Recurrent UTI All six months
• (no reflux or scar)

19
Antibiotic Prophylaxis

• Ideal effective, non toxic with few side
  effects does not alter natural flora does not
  promote resistance
• Cephalexin 10 mg/kg nocte (ideal for lt 3m)
• Cotrimoxazole 2 mg/kg nocte (avoid lt3m)
• Nitrofurantoin 1 mg/kg nocte (avoid in lt 3m,
  renal impairment, GI upset)

20
Measures to reduce recurrent UTI

• Avoid tight undergarments
• Plenty of fluids avoid bladder irritants
• Regular voiding double voiding
• Perineal hygiene avoid shampoo/ soap
• Control constipation
• Circumcision in select group

21
Breakthrough UTI

• Resistant flora
• Poor compliance
• Inadequate dosing
• Poor bladder emptying
• Host immunity
• Address above issues
• double prophylaxis

22
Asymptomatic Bacteriuria

• 1 in girls 0.05 in boys
• Good history and examination
• USG to exclude abnormalities
• Benign condition
• Does not lead to scar
• Often non virulent strain
• Dont treat may get UTI with virulent strain

23
What are the principles in the management of VUR?

• In the absence of UTI, isolated low pressure VUR
  does not lead to scar formation
• Uncomplicated primary reflux resolves
  spontaneously

24
What is the medical management?

• Treat acute episode of UTI
• Start prophylactic antibiotics
• Investigations to exclude anatomical causes of
  secondary VUR
• Treat factors like constipation, dysfunctional
  voiding and bladder instability
• follow-up, parental commitment and patient
  compliance are essential for success

25
How long to continue prophylaxis?

• resolution rate
• Grade I 80 II 60 III 40 IV 10 V 0
• The duration to resolution since diagnosis
• Grade I 2.5 yrs, II 5 years and Grade III and
  IV 8 years
• risk factors for new scarring
• younger age, high-grade reflux, and previous
  scarring
• scarring rate with different grades
• Grade I 10, II 17 and III and above 60.

26
Indications for Surgery

• Anatomical factors duplex, para uret
  diverticulum
• Obstructed refluxing megaureter
• Secondary VUR treat underlying cause
• Primary VUR failure of conservative treatment
• Break through infection worsening function new
  scars
• Poor follow up non compliance
• High grade (IV or V) reflux bilateral reflux
  multiple scars

27
Surgical options

• Circumcision
• STING
• Teflon, macroplastique, deflux, chondrocytes
• Ureteric reimplantation
• Cohen, Leadbetter, Lich Gregoir, laparoscopic
• Transureteroureterostomy
• Heminephrectomy, common channel reimplant
• Nephrectomy

28
Scenario

• A ten-year-old girl, who was initially managed
  medically for grade III VUR (on MCUG), was
  referred to the urologist because she developed
  two episodes of UTI
• A DMSA scan revealed unscarred kidneys with
  normal function
• A repeat MCU confirmed persistent right-sided
  grade III reflux
• On history symptoms of bladder instability
• Treat bladder instability still has symptoms
• Urodynamics examination revealed normal
  compliance with no instability still gets
  recurrent UTIs
• Extravesical reimplantation

29
Thank You!